Nurses’ Perceptions of Ethical Conflicts When Caring for Patients with COVID-19
Abstract
:1. Introduction
2. Methods
2.1. Design and Participants
2.2. Data Collection and Data Sources
2.3. Data Analysis
2.4. Trustworthiness
3. Results
3.1. Theme 1. Ethical Conflicts during the Pandemic
3.2. Ethical Conflicts at the Personal Level
3.3. Ethical Conflicts at the Professional Level
3.3.1. Moral Suffering
3.3.2. Endangering Their Personal Integrity and Their Lives
3.3.3. Poor Patient Death
3.3.4. Neglect of Basic Patient Rights
Autonomy
Beneficence
Justice
3.4. Theme 2. Coping Styles for Dealing with Ethical Conflicts
3.4.1. Autonomous Active Learning or Learning among Peers
3.4.2. Peer Support and Teamwork
3.4.3. Moments of Catharsis and Disconnection through Humor, Music, or Dance
3.4.4. Staying Focused
3.4.5. Accepting the Pandemic as a Work Situation
3.4.6. Forgetting the Bad Situations That Had Occurred
3.4.7. Valuing the Positive Reinforcement of Patients, Their Families, and Society
3.4.8. Humanizing the Situation
4. Discussion
4.1. Theme 1: Ethical Conflicts during the Pandemic
4.2. Theme 2: Coping Styles for Dealing with Ethical Conflicts
4.3. Limitations and Strengths
5. Conclusions
Implications for Nursing Management
Author Contributions
Funding
Institutional Review Board Statement
Informed Consent Statement
Data Availability Statement
Acknowledgments
Conflicts of Interest
References
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Participant Characteristics | n | |
---|---|---|
Age | <30-years-old | 2 |
30–39-years-old | 8 | |
40–49-years-old | 2 | |
>50-years-old | 2 | |
Gender | Male | 3 |
Female | 11 | |
Highest academic qualification | Bachelor’s Degree | 6 |
Specialist | 1 | |
Master | 6 | |
PhD | 1 | |
Type of work | Temporary employment | 9 |
Fixed-term contract | 3 | |
Permanent contract | 2 | |
Type of unit | Intensive care | 6 |
Emergency | 2 | |
Medical unit | 6 | |
Change of unit during COVID-19 crisis | Yes | 3 |
No | 11 | |
Years in practice | 0–4 years | 2 |
5–10 years | 5 | |
11–15 years | 3 | |
More than 25 years | 4 |
Perceptions of nurses’ perceived ethical conflicts during pandemic care: major ethical dilemmas and conflicts. |
Perceptions of nurses who worked on the front line caring for people with COVID-19 on the coping strategies they used to deal with ethical conflicts. |
Perceptions of the impact of ethical conflicts on the personal lives of nurses who worked on the front line caring for people with COVID-19. |
Nurses’ perceptions of the impact of ethical conflicts on the nursing profession in general and on their day-to-day lives as nurses. |
Categories | Codes | Verbatims | ||
---|---|---|---|---|
Ethical conflicts at the personal level | Changes to familiar routines | “For the first fifteen days, for fear of infecting my partner, I voluntarily isolated myself in a room. I would come home from work, take two showers during the shift, during the break and at the end of the shift. When I got home, I went straight into the room without touching anything. My partner prepared a room for me, set up a TV, a small table for me to eat and I ate in the room. I did everything in the room. He would carry the tray of food to the door of the room and leave it on a chair for me. During this time, not a hug, not a kiss… these were forbidden.” (P. 07F32). | ||
Voluntary isolation of family members | “I said <<my first measure will be to be apart from my family and to avoid them (her parents) from teaching any of it>>. I put on a mask, we ventilated the whole house, and they were getting used to a new way of living together… in the end I decided to rent an apartment, so I can be away from my parents so they could live.” (P. 02F45). | |||
Living with other healthcare professionals | “All of us nurses from out of town lived with other nurses. I was living with fellow nurses; we were all in on it for COVID-19 as much as possible. We complied with the measures, you showered at work…you knew you weren’t going to hurt a family member who was out of your scope of work or anything, we were all isolated, we all understood each other. Some colleagues found it hard to rent an apartment or were even encouraged to move house when the pandemic broke out.” (P. 05M30). | |||
Family conflicts | “My partner was crying and asked me not to go to work, not to leave the house. <<Don’t go out, don’t go to work>>.” (P. 07F32). | |||
Temporary career break | “There are colleagues who have quit (taken a leave of absence) simply out of fear. It happened especially at the beginning. They had elderly parents or vulnerable people, what did they do with the parents? On the one hand, I understand it and on the other hand I don’t. Besides being a nurse, you can go to another place to live and have your husband take care of your parents, there are people who have left simply out of fear.” (P. 03F38). | |||
Ethical conflicts at the professional level | Moral suffering | “I don’t like to encounter dead people; I don’t like to see people suffering. I love my profession. I love helping people and being there. I’ve been there every day to take care of my patients, every day, there’s not a day that I haven’t gotten dressed, you know? I don’t know a single person who hasn’t stopped getting dressed for a day. I love grandparents calling your name and asking for your help. So, walking into the rooms and finding someone dead, it may have happened to you once, one night, I don’t know, but here it was, those rooms, those closed room doors, that you started down the hallway, when you got to the end and an hour and a half had passed, they could have been calling out to you and you didn’t hear it, you know, the old people because they were old, but the young people came with pneumonia in such a state that they were not able to ring a bell, they had no strength.” (P. 04F46). | ||
Putting personal integrity and life at risk | “We began to lack equipment; we were already re-sterilizing the masks. There were days when we didn’t have any Filtering Face Pieces 3 (FFP3) masks, which was recommended for intubations, aspirations, etc… I remember the anesthesiologist telling us <<do you have a FFP3 on?>> and we responded <<no, because we don’t have any>>. When my partner and I came out of the shift we hugged each other and cried. We said <<we don’t know if we are going to die>>. Because the feeling we were working with was <<we are going to die>>.” (P. 07F32). | |||
Poor patient death | “It took you three hours to do a round. If it was the first one you were doing, in the next round you found them dead and in a very bad way, they were all blue, or had fallen on the ground… and whoever tells you otherwise is lying. You couldn’t do anything. You went into the rooms and found the people dead … and in a very bad way and alone”. (P. 04F46). | |||
Neglect of basic patient rights | Autonomy | “In people with intellectual disabilities we had to use five-point physical restraints. They were independent people, who moved around… it’s true that they had that disability. They were alone in a room twenty-four hours a day because neither family members nor caregivers came. And we couldn’t be with them inside because of the risk of infection. There was a risk that if you removed the restraints they would touch your face, remove the screen, cough… They were two boys with disabilities, as they were positive, you could not leave them “unrestrained” because we couldn’t risk them doing what they wanted to do at all times, such as leave the room. Therefore, we had to use restraints. For me, to see those kids with this hyperactivity and, giving them medication to make them more relaxed was very distressing. They had restraint marks on their hands from wanting to take them off. That was hard for me because they didn’t understand the situation…” (P. 05M30). | ||
Abandonment of basic patient rights | Beneficence | Doing everything they can for the patient | “I’ve worked more hours than my fair share. I did everything I could. … We did the best we could and the best that we could do at the time. We tried everything, doses and medications were modified, and even so, we have also seen very young people die. But we have all been left with the feeling that we could not have done more…” (P. 06F52). | |
Frustration and helplessness for not being able to save the patient | “I’ve cried a lot because of the helplessness of knowing that you weren’t taking care of them as you should because at the beginning there was so much fear that they were like patients who were hopeless. It didn’t matter how old they were, the first thing we were told was <<if someone stops (cardiorespiratory arrest) they are directly not resuscitable>>, and we knew that if you performed Cardio Pulmonary Resuscitation (CPR) on that person, because maybe they stopped for another reason, not for… maybe they would come out with CPR, but they were not resuscitable…” (P.07F32). | |||
Guilt | “What happened is that we couldn’t give them at the beginning the level of care that you would have given to another type of patient without COVID-19, because you thought it was so contagious, that everything was so dangerous. I am one of the nurses who shakes hands with the patients, even if I am in an isolation suit, with my gloves… I mean, touching their face, and combing their hair, we usually give them a very humanized treatment and suddenly we can’t even touch them, the farther away the better. I think that if there had been more information, the care would have been better, and it would not have generated so much frustration. You go home with a feeling of guilt for not having been able to take care of everything. I know that I have taken care of him, as best as possible, but it’s true that you go home feeling bad because there have been days when we have left at least 25 admissions pending because we had to go up to the ward and the entrance room was full because we just couldn’t take in any more people”. (P.03F38). | |||
Questioning care | “The first few days you’d get home and I, for example, who don’t consider myself a super nervous, super anxious person, I was very worried, did I do things right, did I take off my personal protective equipment (PPE) properly, did I take the right protective measures…?”. (P.01M24). | |||
Duty of care | “In the intensive care unit (ICU) we used the FFP3s per shift because it was safe. If there weren’t enough supplies, we bought them ourselves. If you use this type of mask you can’t afford to use the same one the next day because you are going to infect the other poor guy who just got out of the ICU because he is a little bit better or you are making the COVID-19 disease of whoever is suffering get longer over time because you are over infecting that person, or that person is over infecting you.” (P. 02F45). | |||
Sparing suffering to family members | “During the deaths, when the families called you and asked you <<but did you see that he was in pain, or that he suffered?>> sometimes you didn’t know what to say because of course… The supervisor told us <<you can’t tell the families that it was bad because that is the memory that will remain>> and I really had times when I said <<I have the feeling that I am telling people that no, that he was fine, and that the person was calm… when it isn’t true>>>. But they told us <<you can’t tell that to the families>>. Being on the other end of the phone, I understand it and you have the feeling of saying <<I am lying>>.” (P.03F38). | |||
Justice | Inequity of resources and treatment | “Maybe because you didn’t have time, some patients have died in their room, and you didn’t know if you were going to be able to take them out [to the ICU] or you couldn’t take them out because you had to prioritize. If there was a heart attack or respiratory failure, you had to leave them (they were not considered resuscitable), it happened a lot. And they died because of the infarction… There were no established criteria or protocols… But you more or less knew that you had to leave the patient on the ward because the ICU was collapsed. One criterion we used was age and previous pathologies.” (P.06F52). | ||
Inequity in the allocation of personal protective equipment | “We have realized that apparently some lives were worth more than others because the doctors, when there was no FFP3 for us, for the few times they came in, they came in with an FFP3. They were provided with better material, with more comfortable goggles, and we had ulcers and marks on our faces because we had goggles that were the same for everybody, right? it was our material and that was it. To me, those details hurt a lot because I didn’t expect that differentiation.” (P. 07F32). | |||
Lack of solidarity among professionals | “They came to ask for protective equipment from other units, and we told them that we wouldn’t give it to them because it was for us. We had never done it before, we nurses have always been supportive and this made us feel bad… but we couldn’t do anything else, on our floor they were all positive…” (P. 09F52). | |||
Inequality in exposure to the virus | “I think that the doctors have taken a step back, the nurses have been the ones who have moved forward, the ones who have managed everything. They have left us as the first ones to care, and then the doctor came. Those of us who entered the room were always the nurses and assistants. The doctors were very afraid, they did not enter the room… telling you everything from the doorway. There were things that they had to come into the room to do, but if they could, they avoided doing so. They trusted us, what we told them and what we didn’t, which we valued… It’s true that they gave us a lot of freedom, but of course the problem was that many times you were helpless. It was a totally self-interested trust and so they avoided going in to see the patient. To avoid contact with COVID-19, basically.” (P. 08M32). | |||
Failure of the health system | “Each death is not a failure on our part (nurses) or on behalf of the doctors, it’ s just that we couldn’t… I mean, we couldn’t do anything else. There were patients who had to go down to the ICU to be put on a respirator and if they didn’t go down you knew they were going to die. It’ s a failure of the health system, like everything else. It’s bad luck, because if it had happened fifteen days beforehand there would have been a ventilator for you and now there isn’t…” (P. 10F30). |
Categories | Codes | Verbatims |
---|---|---|
Active learning | Autonomous or peer learning | “We were very scared, we had no training as such, meaning that the Administration did not give us any course with training hours. All the training has been watching videos and documentation at home or learning with co-workers who accompanied you in putting on and taking off the personal protective equipment (PPE) and showed you the steps.” (P. 01M24). |
Use of social networks and internet resources | “I looked for information on the Word Health Organization (WHO) website, on social networks, especially on Twitter, I contacted other professionals from other intensive care units (ICUs) in Spain and they told me what they were doing, I looked for videos of other hospitals in Spain, or other hospitals internationally and I stuck with what I thought could be better or could be better adapted to our unit and that’ s how we were developing the protocols.” (P. 07F32) “We have a special WhatsApp group for COVID-19 where the supervisor passes on all the information, all the protocols that were in place.” (P. 09F52). | |
Outside working hours | “My days off were to watch videos on the internet about respirators, to handle the respirators up to the last detail. To review a thousand protocols, to go over a thousand things, educating myself on a daily basis. I had to leave the ICU and look for information, because since I was isolated, I couldn’t disconnect. 24 h a day thinking about <<what can I do to make this better?>>“. (P. 07F32). | |
Peer support and teamwork | Emotional support | “During the work shift we would get together, we would go out to the terrace, some of us would stay on duty, when you couldn’t take it anymore, when you had to cry, we would go out to the terrace, with another colleague, always accompanied and we would support each other. Emotional support among colleagues was essential, in the team, among nurses and assistants we supported each other”. (P. 06F52). |
Trust | “That was proper teamwork, I trust you and you trust me. We got along well because we knew how to work as a team.” (P. 04F46). | |
Nursing team (nurse and auxiliary nurse care technician) | “As time went by, we realized that we had to change the way we worked and focus on the nurse-assistant team, all working hand in hand. And the truth is that we did it very well, I am very proud of that whole period.” (P. 08M32). | |
Support outside working hours | “Above all, with two colleagues we spent the evenings or mornings when we weren’t on shift talking on the phone a lot, this was vital to feel supported and understood… since there were many things you couldn’t tell your family.” (P. 09F52). | |
Moments of catharsis and disconnection through humor, music, or dance | The media’s distorted image | “When the media talked about the health care workers it was all partying, dancing, laughter, applause… It’ s true that we enjoyed those moments because I myself have danced with my colleagues in the ICU, we played the radio and well, those were moments of disconnection, but what we were experiencing was so intense that it seems that this has not been seen or perhaps they have tried to infantilize people because we were really seeing the worst, what was really happening… however, they come out dancing on television. And it was like… this is not our reality. Those were very specific moments of disconnection, because we need them because it’ s true that people who work in certain special services make certain jokes to try to disconnect, but that’s not what happens during the whole shift. And what we were going through was very strong, then you saw those images and you said <<What kind of image are the public going to have of us?>>, the media is treating the disease as something brutal, people are seeing the morgue opening, the military trucks coming out, the armies disinfecting, and suddenly, we were dancing, I think we were portrayed quite badly.” (P. 07F32). |
Focusing on care and everyday work | Focusing on care | “The feeling that another patient is coming, and I have no idea what we are going to do, what we are doing, that this is going to blow up in our face… So, at three or four o’clock in the morning there came a time when we had to focus and say, let’s plan what we are going to do, let’s call the management and start referring patients because this is going to blow up… I think we did well.” (P. 04F46). |
Accepting the pandemic as a work situation | Professional duty and commitment | “I haven’t thought about running away. That never crossed my mind. I thought that we were in the situation we were in and that we had to move forward and keep fighting. If I had to catch it, that’s it.” (P. 03F38). |
Forgetting bad situations | Dissociative amnesia | “The mind tries not to remember the negative and unpleasant things. I try to evade because I see that at the beginning, I was very tough psychologically, I was very strong but now that all this has happened you fall apart. So, you try not to touch the subject.” (P. 06F52). |
Valuing positive reinforcement from patients, their families, and society | Positive reinforcement | “It definitely reinforces your profession to know that patients thank you, that you’ve been there hanging in, that there are people who have left, and you’ve been hanging in there all along.” (P. 04F46). “The gratitude of the people who have been hospitalized and who have recovered in the end. When you made a video call, both the families and the patients were eternally grateful. They didn’t know who you were because they could see your little eyes, but in that sense, it has been gratifying.” (P. 10F30). |
Support for demanding workplace improvements | “The support we were receiving from society through the applause I personally felt comforted and fulfilled, but always hoping that this would become a real support to improve working conditions, contracts… and to improve the visibility and the concept that society has of health care and nurses. Because I have no use for applause in those moments when we have a noose around our necks and all eyes were on us to move forward. If right now it doesn’t turn into salary improvements, labor improvements…” (P. 01M24). | |
Humanizing the situation | Video calls to family members | “When they started making video calls, I volunteered and made at least four video calls a day. Family members had to request them, and you went with a Tablet, or a cell phone provided by the Health Service. I dedicated many hours to this, instead of leaving at three o’clock, I would leave at half past four, or half past six… whatever time it was.” (P. 06F52). |
The family’s farewell to patients at the end of life | “In cases of terminally ill patients, we provided the relatives with PPE, which we didn’t have a lot of. We tried to humanize the situation a bit. We also made one call a day or every other day with the relatives.” (P. 05F30). |
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Caro-Alonso, P.Á.; Rodríguez-Martín, B.; Rodríguez-Almagro, J.; Chimpén-López, C.; Romero-Blanco, C.; Casado Naranjo, I.; Hernández-Martínez, A.; López-Espuela, F. Nurses’ Perceptions of Ethical Conflicts When Caring for Patients with COVID-19. Int. J. Environ. Res. Public Health 2023, 20, 4763. https://doi.org/10.3390/ijerph20064763
Caro-Alonso PÁ, Rodríguez-Martín B, Rodríguez-Almagro J, Chimpén-López C, Romero-Blanco C, Casado Naranjo I, Hernández-Martínez A, López-Espuela F. Nurses’ Perceptions of Ethical Conflicts When Caring for Patients with COVID-19. International Journal of Environmental Research and Public Health. 2023; 20(6):4763. https://doi.org/10.3390/ijerph20064763
Chicago/Turabian StyleCaro-Alonso, Pedro Ángel, Beatriz Rodríguez-Martín, Julián Rodríguez-Almagro, Carlos Chimpén-López, Cristina Romero-Blanco, Ignacio Casado Naranjo, Antonio Hernández-Martínez, and Fidel López-Espuela. 2023. "Nurses’ Perceptions of Ethical Conflicts When Caring for Patients with COVID-19" International Journal of Environmental Research and Public Health 20, no. 6: 4763. https://doi.org/10.3390/ijerph20064763